Clark-Lindsey Village

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 11 (R1, R4, R6, R7, R8, R12, R13, R14, R17, R18, R31) of 13 residents reviewed for infection control in the sample list of 26. This failure has the potential to affect all 23 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately store and label medications for five (R32, R33, R6, R24, R10) of five residents reviewed for medication storage in the sample list of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to answer the call light timely for a resident that requires assistance with toileting for one of 16 residents (R7) reviewed for dignity on the sample list of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and care plan for self-administration of medication for one of one resident (R12) reviewed for self-administration of medications in the sample list of 26.

Inspectors wroteBased on interview and record review the facility failed to provide safe transfers with a mechanical stand lift on two separate occasions, for one of three residents (R18) reviewed for falls on the sample list of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to have physician orders for Continuous Positive Airway Pressure (CPAP) settings, implement CPAP care/maintenance, and assess vital signs and lung sounds pre/post nebulizer administration for two of two residents (R11, R14) reviewed for respiratory care in the sample list of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications timely and as ordered for two of eight residents (R10, R31) reviewed for medication administration in the sample list of 26. This failure resulted in 5 medication errors out of 27 opportunities resulting in a 18.52% medication error rated.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident rights to review the facility State Survey Agency survey results, by failing to provide resident access to State Survey Agency results. This failure affects all 23 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to protect one (R7) resident's right to be free from abuse and neglect by staff members (V10, V11) out of five residents reviewed for abuse and neglect in a sample list of eight residents. R7 was not provided basic cares such as repositioning and incontinence care timely. R7 was made to cry, scream and yell out in pain as staff refused to assist and reposition R7 during incontinent cares.

Inspectors wroteBased on observation, interview and record review the facility failed to provide Licensed Nurses to administer medications on multiple occasions for one (R7) resident out of five residents reviewed for Improper Nursing Care in a sample list of eight residents.

Inspectors wroteBased on interview and record review the facility failed to maintain accurate medical records for one (R7) resident out of five residents reviewed for Improper Nursing Care in a sample list of eight residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents rights were honored for one (R1) resident out of five residents reviewed for Resident Rights in a sample list of eight residents.

Inspectors wroteBased on interview and record review the facility failed to document, follow up and resolve grievances for one (R7) resident out of five residents reviewed for grievances in a sample list of eight residents.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of neglect for one (R7) resident out of five residents reviewed for Abuse in a sample list of eight residents.

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of neglect for one (R7) resident out of five residents reviewed for Abuse in a sample list of eight residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision was provided during toileting for 1 (R1) of 3 residents reviewed for falls on the sample list of 4. This failure resulted in R1 sustaining multiple acute fractures involving the left humerus.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician admission orders to assess and monitor a surgical site, failed to provide a physician ordered shampoo to use over a surgical site, failed to initiate Enhanced Barrier Precautions (EBP), and failed to update the care plan. These failures resulted in a surgical infection which required additional appointments, antibiotics, a second hospitalization, and surgery for one (R1) resident out of three residents reviewed for Quality Care/Treatment in a sample list of three residents.

Inspectors wroteBased on interview and record review the facility failed to follow their Grievance policy by not following up on a resident (R1) complaint timely for one out of three residents reviewed for grievances in a sample list of three residents.

Inspectors wroteBased on interview and record review the facility failed to timely investigate an accident and update the resident care plan for one (R1) resident out of three residents reviewed for Accidents in a sample list of three residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper wheelchair positioning to prevent a fall, failed to provide safe equipment, and failed to use a mechanical lift for transfers for one (R269) of 16 residents reviewed for accidents on the sample list of 21. These failures resulted in R269 requiring emergency room treatment after falling from a wheelchair and hitting R269's head on the floor. R269 sustained a head injury and a hematoma to the left forehead. These failures also resulted in R269 sustaining skin tears to the left and right forearm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that dietary staff wore the appropriate hair restraints to prevent the potential physical contamination of food, food-contact surfaces, and equipment. This failure has the potential to affect all 20 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record the facility failed to ensure a wheelchair was in safe operating conditions for one (R269) of 16 residents reviewed on the sample list of 21. This failure also had the potential to affect all 20 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately notify the Power of Attorney of an injury. The facility also failed to notify the physician of a significant weight gain for two (R269, R15) of 16 residents reviewed for notification of changes on the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to implement their abuse prevention and prohibition policy for one (R269) of 16 residents reviewed for abuse on the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the State Agency for one (R269) of 16 residents reviewed for abuse on the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of abuse for one (R269) of 16 residents reviewed for abuse on the sample list of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise a care plan for one (R269) of 16 residents reviewed for care plans on the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to develop a plan of care which addressed potential adverse reactions to opioid medications, failed to monitor bowel movements, and failed to treat constipation for one of one resident (R220) reviewed for opioid medications on the sample list of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene and change gloves during and after incontinence care to prevent the risk for urinary tract infection for one (R15) of five residents reviewed for infection control in the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to document behaviors and implemented nonpharmacological interventions prior to increasing antidepressant dosage and failed to attempt a Gradual Dose Reduction (GDR) for one of five residents (R6) reviewed for unnecessary medications in the sample list of 21.

Inspectors wroteBased upon observation, interview, and record review the facility failed to store refrigerated schedule II medications behind double locked compartments, failed to ensure stock medications were not expired, and failed to ensure medications were properly stored in the medication room or medication cart for three (R3, R5, and R11) of six residents reviewed in a sample of 21.

Inspectors wroteBased on observation, interview, and record review the facility to provide diet and liquids in the correct form for one (R269) of 16 residents reviewed for nutrition on the sample list of 21.

Inspectors wroteBased on observation, interview, and record review staff failed to prevent potential cross contamination by failing to change gloves and perform hand hygiene for two (R8 and R15) of sixteen residents reviewed for infection control on sample list of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and foodborne illness, by failing to maintain the facility commercial food mixers in a sanitary manner, free of food-like debris and rust. The facility also failed to wear hair restraints during meal preparation. These failure affects all 12 residents in certified beds.

Inspectors wroteBased on interview and record review the facility failed to ensure call lights were answered in a timely manner for three of five residents (R3, R9, R11) reviewed for call lights on the sample list of 16. Findings Include: 1. R3's admission Record dated 1/18/24 documents R3 is diagnosed with Repeated Falls, Anxiety, Muscle Weakness, Unsteadiness on Feet, Difficulty Walking, and Cognitive Impairment. R3's Care Plan dated 12/19/23 documents R3 is dependent on staff for physical needs and is at risk for falls. The Care Plan documents staff should respond promptly to all requests for assistance. On 1/16/24 at 11:00 AM R3 stated she is unsure of how long it takes staff to answer call lights and she just waits till they come. The Call Light Alarm report documents R3 had a call light response time of twenty-seven minutes six seconds on 01/14/2024 at 7:57 PM. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop their abuse prevention policy to include the prohibition against the use of technology to facilitate or enable abuse or mental abuse. This failure has the potential to affect all 12 residents residing in certified beds in the facility on the sample list of 16. Findings Include: The facility's Bed Change Request Approval letter dated 1/16/24 documents the facility houses 29 resident beds certified under Title 18, Medicare, which are rooms 101, 103 through 118, and 201 through 212. The facility's Resident Roster dated 1/16/24 documents twelve residents currently reside in the facility's certified beds. [...]